1. Functional & Objective Evaluation Of Hypospadias Repair
Benedict Joshua, Dhruv Ghosh, Sanjeev Kumar, Alka Grewal, William Bhatti

2. Aim Functional and Objective Evaluation of Hypospadias Repair
We audited the hypospadias repairs done in our department and evaluated them functionally as well as objectively

3. Methods Inclusion Criteria 6 months after hypospadias urethroplasty
2 month after urethrocutaneous fistula repair
Toilet trained
Toilet trained individuals who had at least a 6 month interval after urethroplasty or 2 months after a fistula repair were included

4. Methods Exclusion Criteria Not Toilet trained
Active Urethrocutaneous fistula
Symptomatic meatal stenosis
Symptomatic urethral stricture
Patients with an untreated urethrocutaneous fistula or symptomatic urethral obstruction were excluded

5. Methods Uroflowmetry Voided Volume Voiding Time Maximum Flow Rate
Average Flow Rate
Voiding Pattern
Evaluation via Toguri’s Normogram1
Functional evaluation was done by Uroflowmetry in our Urodynamics laboratory and Toguri’s normogram used to classify obstructive or non obstructive flow
1. Toguri AG et al. Pediatric Uroflow Normograms. J Urol (1982);127:

6. Methods
Hypospadias Objective Scoring Evaluation (HOSE)2 (Independent Investigator)
Meatal Location
Meatal Shape
Urinary Stream
Erection
Fistula
Max Score: 16
Acceptable Score ≥ 14
An independent investigator not involved in the management or surgery of these patients did the HOSE scoring by interviewing the patient or the primary caregiver
2. Holland AJA et al. HOSE: An Objective Scoring System For Evaluating The Results Of Hypospadias Surgery. BJU Int(2001);88:255

7. Materials 39 patients fulfilled all inclusion criteria
Mean Age (At Surgery): 5.16 years (range: 1-24 yrs)
Mean Age (At Evaluation): 8.5 years (range: 2-25 yrs)
Mean Follow Up: mths (range: 6-148mths)
Amongst the patients who responded to our invitation for evaluation 39 fulfilled the inclusion-exclusion criteria. The demographic profile is presented here.

8. Materials Distal Hypospadias: 53.85% (n=21)
Mid Penile Hypospadias: 17.95% (n=7)
Proximal Hypospadias: 28.20% (n=11)
Distal hypospadias repairs formed more than half the group

9. Qmax Significantly Better In Distal Repairs(p=0.03)
Results
Maximum Urine Flow Rate (Qmax)
Normal:43.59% (n=17)
Distal: 66.7% (n=14)
Mid: 28.6% (n=2)
Proximal: 9.1% (n=1)
Obstructed: 43.59% (n=17)
Distal: 23.8% (n=5)
Mid: 57.1% (n=4)
Proximal: 72.7% (n=8)
Qmax Significantly Better In Distal Repairs(p=0.03)
An equal number of patients showed a normal and an obstructed Qmax while the remainder were equivocal. Normal Qmax was seen in a significantly higher number of distal hypospadias repairs

10. Better Qave In Distal Repairs (p=ns)
Results
Average Flow Rate (Qave)
Normal:17.9% (n=7)
Distal: 28.6% (n=6)
Mid: 14.3% (n=1)
Proximal: 0% (n=0)
Obstructed: 69.3% (n=27)
Distal: 52.4% (n=11)
Mid: 85.7% (n=6)
Proximal: 90.9% (n=10)
Better Qave In Distal Repairs (p=ns)
The Qave was obstructive in a majority of our patients. A slightly better Qave was seen in distal repairs but this difference was not significant

11. Urine Flow Curve Less Obstructive In Distal Repair (p=ns)
Results
Urine Flow Patterns
Normal:33.3% (n=13)
Distal: 47.6% (n=10)
Mid: 28.6% (n=2)
Proximal: 9.1% (n=1)
Obstructed: 66.7% (n=26)
Distal: 52.4% (n=11)
Mid: 71.4% (n=5)
Proximal: 90.9% (n=10)
Urine Flow Curve Less Obstructive In Distal Repair (p=ns)
Again a majority of our patients demonstrated a obstructive urine flow curve. The urine flow curve was less obstructive in distal repairs but not significantly.

12. Qmax Appears to Improve With Time (p=ns)
Results
Follow Up v/s Qmax
Less Than 2 Years
Normal: 27.27% (n=6)
Equivocal: 18.18% (n=4)
Obstructed: 54.55% (n=12)
More Than 2 Years
Normal: 64.71% (n=11)
Equivocal: 5.88% (n=1)
Obstructed: 29.4% (n=5)
Qmax Appears to Improve With Time (p=ns)
Qmax seems to improve as time following repair elapses but there was no statistical significance of this improvement in our study

13. Improvement In Flow Pattern With Time (p=ns)
Results
Follow Up v/s Urine Flow Pattern
≤ 2 Years
Normal: 22.7% (n=5)
Obstructed: 77.3% (n=17)
> 2 Years ≤ 5 Years
Normal: 37.5% (n=3)
Obstructed: 62.5% (n=5)
> 5 Years
Normal: 55.5% (n=5)
Obstructed: 45.5% (n=4)
Improvement In Flow Pattern With Time (p=ns)
Urine flow patterns also gradually seem to improve with time but not significantly

14. Results Post Voidal Residual Volume
Significant (>10% of FBC): 5.13% (n=2)
Not Significant (<10% of FBC): 94.87% (n=37)
Most Patients Voided To Completion Inspite Of Obstructive Flow Patterns & Rates
While a majority of our patients showed obstructive flows and curves, they still managed to void to completion and only 2 children had a significant post voidal residue on ultrasound evaluation

15. Results Cystourethroscopy Patients With Abnormal Flow Rates & Patterns
6 Patients Consented
All Patients Were Asymptomatic
Cystourethroscopy Was Normal In All 6
6 children with abnormal flow patterns including the two with significant post voidal residue consented to cystoscopic evaluation. The cystourethroscopy was normal in all 6, raising the question as to what is contributing to the obstructive patterns.

16. Results HOSE Scoring Satisfactory: 71.79% (n=28)
Distal: 85.7% (n=18)
Mid: 85.7% (n=6)
Proximal: 36.4% (n=4)
Unsatisfactory: 28.21% (n=11)
Distal: 14.3% (n=3)
Mid: 14.3% (n=1)
Proximal: 63.6% (n=7)
Level Of Repair Significantly Related to Final Cosmetic Outcome (p=0.009)
Our cosmetic outcomes were comparable to most series around the world with distal repairs having a significanltly better cosmetic result

17. Discussion Qmax Significantly Related To Level Of Repair
Obstructive Flow Rates & Patterns Did Not Relate To Demonstrated Mechanical Obstruction
What Causes The Obstructive Flow Rates And Patterns?
Cosmetic Outcomes & Patient Satisfaction Related To Level Of Repair